Digoxin Death Knell Sounded At ACC 2017?

Digoxin has been in a state of clinical equipoise for the last few years as evidence mounted suggesting higher mortality in heart failure patients taking it.

At the American College of Cardiology Scientific Sessions Late-Breaking Clinical Trials yesterday a paper (slides here) showing higher mortality for patients on digoxin may be the final nail in the foxglove coffin.

Despite lack of evidence for its safety in the treatment of atrial fibrillation from randomimized trials, digoxin is used in 30% of patients with afib worldwide and current AF guidelines recommend it for rate control in patient with AF with and without heart failure.

The investigators used data from the ARISTOTLE study of apixiban versus warfarin for their analysis.

They looked at mortality in patients taking or not taking digoxin at baseline using a Cox model with propensity weighting which included demographic features as well as biomarkers and digoxin levels at baseline. Major findings:

-In patients already taking digoxin, mortality was not higher in digoxin users, however,the risk of death was related to dig levels: for every 0.5 ng/ml increase in dig level, the risk of death rose by 19 percent and if dig level was >1.2 ng/ml the death rate increased by 56 percent.

-Patients not taking digoxin before the trial who began taking it over the course of the study had a 78 percent increase in the risk of death from any cause and a four-fold increased risk of sudden death after starting digoxin use. Most sudden deaths occurred within six months after digoxin was started. –

-Risk of death with initiation of digoxin was increased in patients with and without heart failure.

The use of foxglove to treat dropsy is a fascinating and instructive chapter in the history of medicine.

This study added to prior systematic reviews suggests that it is time to end the use of digitalis and close the chapter.

William Withering might turn over in his grave but at least we won’t be sending afib patients to join him prematurely!

Are you initiating long term digoxin therapy for your afib or heart failure patients? Login or join SERMO to contribute your opinions to this post.

Dr. Anthony Pearson is a clinical cardiologist and director of noninvasive cardiac imaging at St. Luke’s Hospital in St. Louis, Missouri. In his spare time he plays keyboards and guitar in the band, Dr. P and the Atherosclerotics. Blog: www.theskepticalcardiologist.com | Twitter: @skepcard